Cerebrovascular Accident denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a 62-year-old female enrollee has requested physical therapy for the treatment of her rehabilitation post cerebrovascular accident. Findings: The physician reviewer found that this patient has had recurrent decline in her functional mobility after her skilled physical therapy was discontinued. After each bout of physical therapy, the patient would show improvement, but when she was discharged and transferred to the restorative nursing department, she would decline in function. At the time of discharge from her most recent bout of physical therapy treatment, she required minimal assistance with mobility and ambulation (up to 100 feet with a front wheeled walker). Skilled physical therapy is medically necessary if there is an expectation of significant improvement in a reasonable amount of time and also to prevent decline.

The representative of a 65-year-old male enrollee has requested continued rehabilitation services (physical and occupational therapy) at a skilled nursing facility for the treatment of the enrollee, who is status post CVA. Findings: The physician reviewer found that the rationale for the denial appears to be related to social resources. The patient was denied continued rehabilitation because he would remain in a skilled nursing facility and require 24 hour supervision. The rationale is independent of the clinical progress he was making, albeit slowly. On 5/29/08, the patient required moderate assistance with bed mobility and moderate/minimal assistance with transfers. Two weeks prior, he was moderate/maximum to maximum assist in these modalities. He showed similar progress with occupational therapy. His progress precludes predicting what his precise functional gain will be.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for inpatient admission to any tertiary care center for interdisciplinary assessment and stabilization. An inpatient rehabilitation facility (IRF) provides hospital-level care to stroke survivors who need intensive, 24-hour-a-day, interdisciplinary rehabilitation care that is provided under the direct supervision of a physician. Admission to IRFs should be limited to patients for whom significant improvement is expected within a reasonable length of time and who are likely to return to a community setting, rather than being transferred to another setting such as a skilled nursing facility or a long-term care facility. According to an expert, “Most stroke deficits will see the highest rate of recovery during the first three to six months after stroke.

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient acute rehabilitation services for the treatment of her cerebrovascular accident. Findings: The physician reviewer found that in this clinical setting, inpatient acute rehabilitation services are not medically necessary for treatment of this patient’s medical condition. Per standards of care in the practice of rehabilitation medicine, acute inpatient rehabilitation is not necessary if appropriate care meeting a patient’s clinical and rehabilitation needs can be provided at a less intensive level of care. Functional impairments due to acquired brain insults such as stroke can improve with time, i.e., natural recovery processes; but, are also amenable to rehabilitation interventions.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving cerebrovascular accident, then check the rights and deadlines that apply to your plan.